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John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

One of the things I hear people talk about all the time is how much time they spend charting in their EMR. There’s little question that doctors, nurses, and front desk staff’s lives revolve around an EMR when one is implemented in an office. However, the same was true with the paper chart.

How many times have we hear doctors say, “I’ve got a stack of paper charts I have to finish.”? Or the phrase, “I’m drowning in charting.” It happened all the time even in the paper chart world. Why else would a doctor take a stack of paper charts home with them in their car. It wasn’t for some light reading at night. It was so they could catch up on their paper charting (yes, some took them home for their hospital rounds too).

Don’t get me wrong here. I’m not saying that we should give inefficient and poorly designed EMR software a pass. Absolutely not! I am saying that far too many people forget how inefficient paper could be and how the charting and documentation requirements took a lot of time before EMR as well.

In my EHR benefits series, I wrote about the efficiency benefits of Legible Notes and Accessible Charts. I’ve heard many doctors talk about how templates help make them more efficient when it comes to charting. I know many doctors who can touch type so quickly that they can’t imagine writing a paper chart anymore. I know many doctors who use a scribe and see amazing efficiency with charting.

On the other side, I know some who hate their EMR. Their EMR is so slow that they can barely chart in it. They get overwhelmed by the clicks. They spend hours trying to find the right diagnosis or code or template. They have stacks of EMR charts waiting for them to finish charting.

The reality is that you can paint the EMR picture either way. I’ve seen both sides of the story happen many times. However, far too many who ridicule the inefficiencies of EMR seem to forget the inefficiency of paper.

11 responses to "Don’t Act Like Charting on Paper Was Fast"

I hear the same message too; all the time. It boils down to two things.

1. I want to interact with the patient rather than the screen and I want to do EMR in the same time or less than what it took me to scribble something on paper.
AND
2. I don’t want to take paper home, I want to go home early.

Notice I did not mention other efficiencies for the entire practice? When Providers are evaluating the system, this is what they look at and leave other stuff to their administrators.

Do you have any studies to back up any of these thoughts? Yes, many providers have stacks of charts in their offices, but they also have stacks of tasks in their EMRs that they’re working on at home while their kids are playing and trying to get their attention.

mike,
I think I’ve seen a few studies on EHR efficiency, but I can’t remember that were any good. Plus, I’ve never seen one take into account how much time was spent on paper charting.

It’s all anecdotal, but the point of my post was just to help doctors remember that they’re not coming from a place of perfect efficiency. Maybe EHR isn’t as efficient as it could or should be yet, but how does it compare to paper chart efficiency?

I went with a family member to another practice today and made some observations and asked some questions. At the front desk, a practice management system was obviously in use. No big deal or surprise. Got to an exam room, not a hint of the existence of computers. Doctor comes in, I’m guessing he’s in his 50’s, and he’s carrying a paper chart. He makes notes on paper throughout the visit. At the end, I ask him if the practice will be implementing an EHR. He announces – oh, we have one, and it’s really nice. All he has to do is write down his notes, go back to his office later and dictate all his notes, and then someone eventually enters them into the system! He was especially proud that he had remote access to the system – which he clearly didn’t seem to want to use while in the office.

I also asked him about patient data in the nearby hospital he’s connected to. He was happy to say that he can log into that system to look things up. I asked if he could interchange data with it, and he thought about it, and told me that he can print out things from the hospital system and then have someone scan the printouts into the office system. He gave my family member a prescription for a blood test to be done during that person’s upcoming outpatient visit to the hospital – on paper, of course. I asked him if the system had a patient portal; he had no idea of what I was talking about. He also clearly had no idea that EHR’s of doctor’s practices might be linkable to other practices (helping the same patients) and hospitals.

Earlier that day I’d been with another doctor, one I mentioned recently. She sometimes does her own entries, sometimes she uses an aide as a scribe. By the time the patient leaves, the system updates are done. Oh, and they are readable, and they don’t require her to spend a pile of time dictating them so someone else can hopefully correctly type them in later. And when she does a prescription, if you want it goes directly to your pharmacy, if not it gets printed out – fully readable. She has clearly become quite efficient one way or another in using her practice’s EHR, while the other doctor is still back in the dictating machine age.

First, let me say that I am not a technophobe. In general, I think machines CAN do tasks more efficiently than tasks can be done by hand. The problem I see re: “perception” is the unrealistic one that appropriately documenting a progress note for today’s visit in an EHR is supposed to be a place where a physician realizes efficiency over paper documentation methods

Sure a physician can “click” on a template that explodes into a massive note that he/she can cursorily (if that’s the word) “edit” to supposedly reflect the actual work performed that day. However, that’s often not an appropriately documented note. As an E/M auditor (and one who works as an E/M expert for the defense in fraud litigation), I can say with 100% certainty that a templated note (ie, the really “efficient” one) rarely, if ever, matches what actually went on in the exam room during that encounter. While with paper charting physicians may have forgotten to document something they did (usually pertinent negatives for either ROS or exam), the problem with templates is that the resulting documentation is so full of stuff that the physician didn’t do (ie, they forgot to edit it out) that the clinical integrity of the note is rendered nearly worthless.

If a physician is committed to having an EHR progress note that accurately matches what he/she actually asked and examined during that encounter, THOSE kind of notes take as long to create (if not longer, depending on the individual’s typing speed) as the old “paper” chart entries used to take.

If we want physicians to stop hating their EHRs — if we want to stop setting up physicians for a world of heartache when their EHR records are audited and downcoded for lack of medical necessity for the extent of the work up documented — then I think the folks SELLING these records need to provide realistic expectations for their potential clients. Specifically, they need to tell docs that the time saving/efficiency comes from not having to wait to see the patient until the paper chart is located. It comes from being able to “CLICK” for Rx renewals (rather than having to double document them — once in the note and once on the paper that the patient takes). It comes from being able to review labs and other diagnostic test results more efficiently — and to be able to retrieve those more efficiently. And it comes from being able to do all kinds of OTHER things with the data recorded in the EHR that were cumbersome to do by hand before. But it does NOT come from saving them time on charting their own progress notes.

The process of patient assessment (which is what is reflected by an E/M service)is a highly gestalt process and therefore one that’s not easily template-able, except to the extent that the template is specific to a presenting problem. And even then, that presumes that the patient is coming in with only one complaint. That may be true is some very highly specialized practices (opthalmology, for example). But for those practices that see a variety of different complaints — many of which may occur within a single encounter for one patient — the use of a pre-filled template with “generic” information that is to be edited is simply incompatible with the cognitive processes involved in the process of patient assessment. When I read these notes, the term I use is “sanitized”. Since it is EXTREMELY difficult to accurately edit your own work, the end result in the vast majority of progress notes is that the note is so sanitized as to make it extremely difficult, if not impossible, to figure out exactly what was going on in this clinical encounter.

I don’t know many people — physicians included — who LIKE the “paperwork” part of their professional activities. For most of us, sitting down to do the necessary “paperwork” to record the professional services we’ve provided that day is as enjoyable as having a root canal without Novocaine. Unfortunately, because most (virtually all??) EHR vendors have designed their software with “templates” in mind, those physicians who are committed to have progress notes that reflect the work they actually did (ie, those than shun templated documentation) find that the use of the software is extremely onerous simply because “efficiency” outside of the use of templates (or template-like functionality) doesn’t exist in this generation of EMR software programs. Do they have all kind of other cool bells and whistles for overall PRACTICE efficiency? Sure they do. But vendors have universally missed the mark, IMHO, of creating software that makes the process of getting an ACCURATE progress note an efficient one.

(btw, an accurate progress note is one that contains EXACTLY — no more or no less — what would be seen on a video recording of what went in the exam room during the encounter)

Again. I’m not a technophobe. I wholeheartedly embrace the myriad of benefits that EHRs have the potential to bring to the practice of medicine. But vendors have a long way to go in creating software that facilitates BOTH accurate and efficient progress note documentation process.

Since CMS does not consider the volume of documentation to be the sole criterion on which the level of E/M service should be selected (per Pub 100-4, Chapter 12, Section 30.6.1 — and as seen in innumerable Medicare contractor audits over the past 18-24 months), today’s physicians need EMR software that helps them paint the medical necessity for the extent of the E/M service they ultimately bill for. Use of templates or highly templated documentation is simply the antithesis of this.

Recently I had several visits to one specialist. At times, depending on which of several offices she rotated between, plus what she was doing, she had a scribe taking notes. But sooner or later, she sat down at the PC and entered in highly detailed notes on her exam and treatment. It was clear that she wanted to be able to track treatment and results, and that when I’d come back later for a follow up she knew she would have the records that she needed without worrying about lost sheets, charts that didn’t get there on time, bad handwriting, etc. She’s young, having recently finished advanced training in her field, and determined to make good use of the technology to take better care of her patients. I’m guessing that most aspects of MU come naturally to her, that they are welcome to her. She’s also thinking about how she can extend the use of the EHR with imaging and the like.

This discussion ignores one important issue; how well, how quickly can a doctor pull up past info and trends on the EHR. Can a doctor spot trends from treatments? Are the treatments working? Can an optometrist note ongoing changes in a patient’s vision (to make decisions on the suitability of, for example, certain laser eye surgery)? Are treatments having negative effects on blood pressure or weight? Etc. I watch doctors who’ve treated a patient for years unable to see what’s really going on from a foot high stack of paper. A well organized EHR with decent analytics could make a huge difference.

[…] worth nothing that templates offer some relief over paper charting duties. As John Lynn notes, doctors have historically had to go through stacks and stacks of paper to do traditional charting, often bringing home piles of charts just to stay caught up. That sort of backlog has consequences […]

[…] on the issues with EHR software. In many ways, the post reminded me of my post titled “Don’t Act Like Charting on Paper Was Fast.” In that post, I highlight the fact that far too many people are comparing EHR against doing […]

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